Clinical benefit of adenosine as an adjunct to reperfusion in ST-elevation myocardial infarction patients: An updated meta-analysis of randomized controlled trials

Background: Adenosine administered as an adjunct to reperfusion can reduce coronary no-reflow and limit myocardial infarct (MI) size in ST-segment elevation myocardial infarction (STEMI) patients. Whether adjunctive adenosine therapy can improve clinical outcomes in reperfused STEMI patients is not clear and is investigated in this meta-analysis of 13 randomized controlled trials (RCTs). Methods: We performed an up-to-date search for all RCTs investigating adenosine as an adjunct to reperfusion in STEMI patients. We calculated pooled relative risks using a fixed-effect meta-analysis assessing the impact of adjunctive adenosine therapy on major clinical endpoint including all-cause mortality, non-fatal myocardial infarction, and heart failure. Surrogate markers of reperfusion were also analyzed. Results: 13 RCTs (4273 STEMI patients) were identified and divided into 2 subgroups: intracoronary adenosine versus control (8 RCTs) and intravenous adenosine versus control (5 RCTs). In patients administered intracoronary adenosine, the incidence of heart failure was significantly lower (risk ratio [RR] 0.44 [95% CI 0.25–0.78], P = 0.005) and the incidence of coronary no-reflow was reduced (RR for TIMI flow<3 postreperfusion 0.68 [95% CI 0.47–0.99], P = 0.04). There was no difference in heart failure incidence in the intravenous adenosine group but most RCTs in this subgroup were from the thrombolysis era. There was no difference in non-fatal MI or all-cause mortality in both subgroups. Conclusion: We find evidence of improved clinical outcome in terms of less heart failure in STEMI patients administered intracoronary adenosine as an adjunct to reperfusion. This finding will need to be confirmed in a large adequately powered prospective RCT

Fractional Flow Reserve in the Transradial Era: Will Hand Vein Adenosine Infusion Suffice? A Comparative Study of the Extent, Rapidity, and Stability of Hyperemia From Hand and Femoral Venous Routes of Adenosine Administration

AbstractObjectivesThe aim of this study was to assess adenosine infusion via a cannula in the back of the hand compared with central venous access to achieve peak hyperemia during fractional flow reserve (FFR).BackgroundAdenosine is often used to induce maximal hyperemia when measuring FFR. The gold standard is continuous infusion via a large central vein; however, the increasing use of the transradial route for angiography makes it desirable to have an alternative route for adenosine. Peripheral venous access is frequently obtained in the hand, but concern exists as to whether adenosine delivery from this site can achieve adequate vasodilation for accurate FFR measurement. Our aim was to address this.MethodsSubjects were selected from patients presenting for coronary angiography/intervention who required a pressure-wire study. Subjects received intravenous adenosine infusion sequentially via 2 routes: first, via a 20-gauge hand cannula, and then, after a washout period, via a 5- or 6-F femoral venous sheath. Adenosine was administered at 140 μg/kg/min from each site. Data interpretation was blinded. Minimal FFR achieved with intravenous adenosine from each infusion site was recorded as was the time to peak hyperemia.ResultsPaired (hand and femoral adenosine) recordings taken from 84 vessels in 61 patients were suitable for blinded analysis. The mean FFR measured using adenosine administered via hand and femoral routes was 0.85 with an SD of 0.08 (intraclass correlation = 0.986). Time to peak hyperemia was longer on average with hand-administered adenosine compared with femoral adenosine administration (63 s vs. 43 s; mean difference, 22 s with a 95% confidence interval: 18 s to 27 s; p < 0.0001). Formal comparison of FFR stability using Mann-Whitney analysis (2 tailed) gives p = 0.43, indicating no significant evidence of a difference in stability between the 2 routes.ConclusionsHand vein adenosine infusion produced FFR values very similar to those obtained using central femoral vein adenosine administration, with no systematic bias toward higher or lower reading from 1 site. This has important practical implications for radial access cases involving pressure-wire studies

Intracoronary imaging guided percutaneous coronary intervention outcomes among individuals with cardiogenic shock

BACKGROUND: Limited data exist around the utility of intracoronary imaging (ICI) during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and cardiogenic shock (CS), who are inherently at a high risk of stent thrombosis (ST). METHODS: All PCI procedures for ACS patients with CS in England and Wales between 2014 and 2020 were retrospectively analysed, stratified into two groups: ICI and angiography-guided groups. Multivariable logistic regression analyses were performed to examine odds ratios (OR) of in-hospital outcomes, including major adverse cardiovascular and cerebrovascular events (MACCE; composite of all-cause mortality, acute stroke/transient ischaemic attack (TIA), and reinfarction) and major bleeding, in the ICI-guided group compared with angiography-guided PCI. RESULTS: Of 15,738 PCI procedures, 1240(7.9%) were ICI-guided. The rate of ICI use amongst those with CS more than doubled from 2014 (5.7%) to 2020 (13.3%). The ICI-guided group were predominantly younger, males, with a higher proportion of non-ST-elevation ACS and ST. MACCE was significantly lower in the ICI-guided group compared with the angiography-guided group (crude: 29.8% vs. 38.2%, adjusted odds ratio (OR) 0.65 95% confidence interval [CI] 0.56-0.76), driven by lower all-cause mortality (28.6% vs. 37.0%, OR 0.65 95% CI 0.55-0.75). There were no differences in other secondary outcomes between groups. CONCLUSION: ICI use among CS patients has more than doubled over 6 years but remains significantly under-utilized, with less than 1-in-6 patients in receipt of ICI-guided PCI by 2020. ICI-guided PCI is associated with prognostic benefits in CS patients and should be more frequently utilized to increase their long-term survival

Increased Radial Access Is Not Associated With Worse Femoral Outcomes for Percutaneous Coronary Intervention in the United Kingdom.

BACKGROUND: The radial artery is increasingly adopted as the primary access site for cardiac catheterization because of patient preference, lower bleeding rates, cost effectiveness, and reduced risk of mortality in high-risk patient groups. Concerns have been expressed that operators/centers have become increasingly unfamiliar with transfemoral access. The aim of this study was to assess whether a change in access site practice toward transradial access nationally has led to worse outcomes in percutaneous coronary intervention procedures performed through the transfemoral access approach. METHODS AND RESULTS: Using the British Cardiovascular Intervention Society (BCIS) database, a retrospective analysis of 235 250 transfemoral access percutaneous coronary intervention procedures was undertaken in all 92 centers in England and Wales between 2007 and 2013. Recent femoral proportion and recent femoral volume were determined, and in-hospital vascular complications and 30-day mortality were evaluated. After case-mix adjustment, no independent association was observed between 30-day mortality for cases undertaken through the transfemoral access and center femoral proportion, the risk-adjusted odds ratio for recent femoral proportion was nonsignificant (odds ratio, 0.99; 95% confidence interval, 0.97-1.02; P=0.472 per 0.1 increase in proportion), and similarly recent femoral volume (per 100 procedures) was not found to be significant (odds ratio, 1.00; 95% confidence interval, 0.98-1.01; P=0.869). The in-hospital vascular complication rate was 1.0%, and this outcome was not significantly associated with recent femoral proportion after risk-adjustment (odds ratio, 0.97; 95% confidence interval, 0.94-1.00; P=0.060 per 0.1 increase in proportion). CONCLUSIONS: The outcome gains achieved by the national adoption of radial access are not associated with a loss of femoral proficiency, and centers should be encouraged to continue to adopt radial access as the default access site for percutaneous coronary intervention wherever possible in line with current best evidence

Defining left ventricular remodeling following acute ST-segment elevation myocardial infarction using cardiovascular magnetic resonance.

The assessment of post-myocardial infarction (MI) left ventricular (LV) remodeling by cardiovascular magnetic resonance (CMR) currently uses criteria defined by echocardiography. Our aim was to provide CMR criteria for assessing LV remodeling following acute MI.This article is freely available via Open Access. Click on the Additional Link above to access the full-text via the publisher's site

Outcomes From Selective Use of Thrombectomy in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction: An Analysis of the British Cardiovascular Intervention Society/National Institute for Cardiovascular Outcomes Research (BCIS-NICOR) Registry, 2006-2013.

AbstractObjectivesThis study used a large national cohort to examine patterns of thrombectomy use in ST-segment elevation myocardial infarction (STEMI) and the relationship to mortality.BackgroundThe impact of coronary thrombectomy on mortality in STEMI has not been definitively established. Published trial data have been insufficiently powered to address this.MethodsThe U.K. national registry was used to study 98,176 patients treated with primary percutaneous coronary intervention (PCI), between January 1, 2006, and December 31, 2013. Patients were grouped on the basis of whether they received thrombectomy or not; subgroups of simple (manual aspiration) and complex (mechanical) thrombectomy were also evaluated. The primary endpoint was 30-day mortality. The principal adjusted analysis used propensity score matching (PSM). A sensitivity analysis was performed using logistic regression controlled for the propensity score.ResultsThrombectomy use markedly increased in the United Kingdom between 2008 and 2010 but plateaued thereafter at slightly below 50% of all primary PCI cases. No significant mortality difference was seen, in adjusted analyses, between the overall thrombectomy group and the no thrombectomy group, at 30 days or 1 year (at 30 days, PSM average treatment effect [ATE] coefficient 0.0028, 95% confidence interval: −0.0048 to 0.0104; p = 0.47). Likewise, no difference was seen between the simple (manual) thrombectomy versus no thrombectomy, at either time point (at 30 days, PSM ATE coefficient 0.0007, 95% confidence interval: −0.0049 to 0.0063; p = 0.80). By contrast, the complex (mechanical) thrombectomy group demonstrated a significantly higher mortality than the no thrombectomy group at 1-year follow-up (PSM ATE coefficient 0.0434, 95% confidence interval: 0.0081 to 0.0786; p = 0.017).ConclusionsCoronary thrombectomy was not associated with lower mortality in primary PCI for STEMI when used in our large all-comer cohort in a selective manner on the basis of physician judgment. These findings are consistent with other negative clinical outcomes in recent large randomized controlled trials studying routine manual thrombectomy in primary PCI

Clinical benefit of adenosine as an adjunct to reperfusion in ST-elevation myocardial infarction patients : An updated meta-analysis of randomized controlled trials

This work was supported by the British Heart Foundation (FS/10/039/28270), the RoseTrees Trust, and the National Institute for HealthResearch University College London Hospitals Biomedical Research Centre.Adenosine administered as an adjunct to reperfusion can reduce coronary no-reflow and limit myocardial infarct (MI) size in ST-segment elevation myocardial infarction (STEMI) patients. Whether adjunctive adenosine therapy can improve clinical outcomes in reperfused STEMI patients is not clear and is investigated in this meta-analysis of 13 randomized controlled trials (RCTs). We performed an up-to-date search for all RCTs investigating adenosine as an adjunct to reperfusion in STEMI patients. We calculated pooled relative risks using a fixed-effect meta-analysis assessing the impact of adjunctive adenosine therapy on major clinical endpoint including all-cause mortality, non-fatal myocardial infarction, and heart failure. Surrogate markers of reperfusion were also analyzed. 13 RCTs (4273 STEMI patients) were identified and divided into 2 subgroups: intracoronary adenosine versus control (8 RCTs) and intravenous adenosine versus control (5 RCTs). In patients administered intracoronary adenosine, the incidence of heart failure was significantly lower (risk ratio [RR] 0.44 [95% CI 0.25-0.78], P = 0.005) and the incidence of coronary no-reflow was reduced (RR for TIMI flow<3 postreperfusion 0.68 [95% CI 0.47-0.99], P = 0.04). There was no difference in heart failure incidence in the intravenous adenosine group but most RCTs in this subgroup were from the thrombolysis era. There was no difference in non-fatal MI or all-cause mortality in both subgroups. We find evidence of improved clinical outcome in terms of less heart failure in STEMI patients administered intracoronary adenosine as an adjunct to reperfusion. This finding will need to be confirmed in a large adequately powered prospective RCT

Intracoronary imaging guided percutaneous coronary intervention outcomes among individuals with cardiogenic shock

Background: Limited data exist around the utility of intracoronary imaging (ICI) during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and cardiogenic shock (CS), who are inherently at a high risk of stent thrombosis (ST). Methods: All PCI procedures for ACS patients with CS in England and Wales between 2014 and 2020 were retrospectively analysed, stratified into two groups: ICI and angiography‐guided groups. Multivariable logistic regression analyses were performed to examine odds ratios (OR) of in‐hospital outcomes, including major adverse cardiovascular and cerebrovascular events (MACCE; composite of all‐cause mortality, acute stroke/transient ischaemic attack (TIA), and reinfarction) and major bleeding, in the ICI‐guided group compared with angiography‐guided PCI. Results: Of 15,738 PCI procedures, 1240(7.9%) were ICI‐guided. The rate of ICI use amongst those with CS more than doubled from 2014 (5.7%) to 2020 (13.3%). The ICI‐guided group were predominantly younger, males, with a higher proportion of non‐ST‐elevation ACS and ST. MACCE was significantly lower in the ICI‐guided group compared with the angiography‐guided group (crude: 29.8% vs. 38.2%, adjusted odds ratio (OR) 0.65 95% confidence interval [CI] 0.56–0.76), driven by lower all‐cause mortality (28.6% vs. 37.0%, OR 0.65 95% CI 0.55–0.75). There were no differences in other secondary outcomes between groups. Conclusion: ICI use among CS patients has more than doubled over 6 years but remains significantly under‐utilized, with less than 1‐in‐6 patients in receipt of ICI‐guided PCI by 2020. ICI‐guided PCI is associated with prognostic benefits in CS patients and should be more frequently utilized to increase their long‐term survival